Local Health Services and Democratic Involvement

– in the House of Commons at 12:33 pm on 21 October 2009.

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Motion for leave to introduce a Bill (Standing Order No. 23)

Photo of John Pugh John Pugh Shadow Minister (Health), Shadow Minister (Treasury) 12:35, 21 October 2009

I beg to move,

That leave be given to bring in a Bill to require Primary Care Trusts to obtain prior approval for their spending plans;
to require Primary Care Trusts to present an annual spending plan to certain local authorities for approval;
to provide resolution arrangements in the event of Primary Care Trusts failing to secure the consent of the relevant local authority;
and for connected purposes.

Judging by the Bill's placing in the parliamentary timetable, I harbour few illusions about the odds on it making it to the statute book, unless fellow Members, or you, Mr. Speaker, are so impressed-clearly, you are not-by its obvious merit as to vary existing procedure. However, my Bill encapsulates a huge issue in this and the past few Parliaments: the democratic deficit in the NHS-the local NHS.

The local NHS is a huge taxpayer-funded service, affects everyone, is important to everyone, but is sadly totally remote from democratic decision making. Those who take the trouble to get elected to secure a mandate can make decisions about who goes to jail, who goes to war, who is taxed, who has power and who does not. We can make decisions about people's daily behaviour: what they may say, whom they may marry, what they may buy and sell, where they may smoke and what, but not about what happens in the local NHS in their area. Those decisions are made by enlightened quangos or trusts, and they are usually a combination of medical experts and appointees who may or may not bring relevant expertise with them. They decide what drugs are available, which hospitals or hospital departments stay open, where services are, how GPs and dentists shape up, and what after-hours care exists. All those issues mean a lot to some people part of the time, and much to all people most of the time.

MPs can protest at the actions of such bodies, as I did when my town lost its children's A and E service. We can plead for their intervention, as when we cajoled them into producing plans for a minor injuries unit. We can present petitions, and express concerns. But the thought of allowing anyone who has gone through the sordid process of getting elected anywhere near decision making has given successive Governments the vapours, and has been resisted hook, line and sinker, much to the satisfaction of hospital chief executives and health service managers.

Afraid to speak their minds, Ministers and mandarins have offered instead various sops. There were the community health councils-well-understood sounding boards, but bolshie enough to get abolished. There were PALS-patient advice and liaison service-the short-lived, worthy but ineffectual feedback collector. Now there are the mysteriously named and constructed LINks-local involvement networks. All were set up by successive pieces of legislation with the function of scrutinising, informing, listening, collating, airing and hearing, involving and consulting-anything, but never deciding.

All that is done on the mistaken assumption that the general public are too stupid to notice that they have absolutely no power over what happens in their local NHS. When an MP raises in this place decisions that their constituents oppose, and tasks a Minister about it, time and again the Minister, with almost comic sincerity, in Pontius Pilate fashion, says, "This is a matter for local decision making," as though "local decision making" implied that local people-outside the quango circle-had any part in it.

That is a perversion of democracy, but it satisfies the professionals, who like the prescription and genuinely fear the alternative-democratic accountability. It would be refreshing if Ministers said what is on their, or the Department of Health's, mind-what they really thought, but dare not say. What they think is that democratic decision making would lead to unworkable populism, that expert government is better than public governance, and possibly that the calibre of those elected is not up to the job-they may be too stupid or ill informed, even though many of the elected reappear on health quangos as appointees wearing different hats. They really think that this public service wants no genuine, local public voice-that that way madness lies. If a Minister actually said that, such a refreshing overt, clear declaration would flush out this argument for the fatuous nonsense that it is.

Democratically elected representatives can only espouse naked unthinking populism-which is what is feared-when they do not have to pick up the tab, run the budget or bear the consequences. Democratic bodies put up taxes, impose parking charges, change refuse arrangements, declare war, cut benefit and close facilities. I see no reason why they cannot make tough decisions, and no evidence to support that view. Democratic bodies also make a host of very technical decisions, competently, when aided by good professional advice.

For the reasons that I have given-solid and good reasons-the Liberal Democrats are very comfortable with the idea of elected health boards. We believe in removing appointees who have been whisked smugly, or in some cases humbly, into power because they have impressed some other appointee who has previously been whisked smugly or humbly into power, and replacing them with elected individuals who have had to impress the citizens served by the local trust, who gain community support and approval, and who, ultimately, justify their position to the people whom they serve.

My Bill is simply a bridge to that position. It involves even less change, and uses existing institutions. I propose that primary care trusts, as currently constituted, lay before the health scrutiny committees of existing councils, as currently constituted, their annual plans and their big decisions-not for scrutiny or consultation, but for approval, agreement and amendment. I propose a kind of democratic lock on the local NHS: a move beyond mere consultation. I propose a genuine redistribution of power from one existing institution to another existing, established institution. This is such a good idea that I believe that the model has already been embraced voluntarily in some areas.

There are likely to be disputes of substance between the PCTs and the health scrutiny committees. There are likely to be sharp differences on how to commit existing resources, given that resources are always limited. The PCT may suggest that maternity services be decommissioned, and the tribunes of the people-the council-may object. What one wants, the other may regard as plain unsafe. The Bill therefore contains a resolution procedure including, eventually, a reference upwards to the Secretary of State as a last resort.

I genuinely see no reason why this model cannot work-in fact, it does work- and produce not simply good decisions, but good decisions with a popular mandate. That would be nice. Our NHS could be reclaimed, without micro-management or meddling, and not with government by experts but with popular government, expertly informed.

Question put and agreed to.

Ordered,

That Dr. John Pugh, Andrew George, Annette Brooke, Paul Holmes, Andrew Stunell, Mark Hunter, Mr. Adrian Sanders and Mr. David Heath present the Bill

Dr. John Pugh accordingly presented the Bill.

Bill read the First time; to be read a Second time on Friday 23 October and to be printed (Bill 152).